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Overview

Pediatricians say you should but it's okay if you don't. The hospital says, "Breast is best," but sends you home with formula "just in case." Your sister-in-law says, "Of course you should!" Your mother says, "I didn't, and you turned out just fine." Celebrities are photographed nursing in public, yet breastfeeding mothers are asked to cover up in malls and on airplanes. Breastfeeding is a private act, yet everyone has an opinion about it. How did feeding our babies get so complicated?

Journalist and infant health advocate Kimberly Seals Allers breaks breastfeeding out of the realm of "personal choice" and shows our broader connection to an industrialized food system that begins at birth, the fallout of feminist ideals, and the federal policies that are far from family friendly. The Big Letdown uncovers the multibillion-dollar forces battling to replace mothers' milk and the failure of the medical establishment to protect infant health. Weaving together research and personal stories with original reporting on medicine, big pharma, and hospitals, Kimberly Seals Allers shows how mothers and babies have been abandoned by all the forces that should be supporting families from the startand what we can do to help.

Product Details

About the Author

KIMBERLY SEALS ALLERS is an award-winning journalist, and leading breastfeeding commentator. Her work has been featured in the New York Times,Huffington Post, The Daily Beast, CNN.com, Ladies Home Journal, The New York Daily News, Real Simple, Fortune, Pregnancy and many others. She has appeared on Good Morning America, CNN, Anderson Cooper, Fox News and the Huckabee Show and NPR. Kimberly worked at Fortune, Essence, New York Post and The Times (of London), before turning to freelance work. She is the author of The Mocha Manual® series of books and the co-author of Giving Notice: Why the Best and Brightest are Leaving the Workplace.

How Medicine, Big Business and Feminism Undermine Breastfeeding

St. Martin's Press

We have not lost faith, but we have transferred it from God to the medical profession.

— GEORGE BERNARD SHAW

I distinctly remember my anxiousness as a new mother just before a pediatrician visit. The visit starts with the inevitable weigh-in and then the height and head circumference, followed by a breakdown of where my daughter sized up on the chart compared with other babies. In our comparison-prone world, growth charts and growth percentiles are like SAT scores for babies. This is how we judge them — by weight gain. Growth percentiles rank your child based on what percent of the reference population your child would equal or exceed. For example, on the weight-for-age growth charts, a two-month-old girl whose weight is at the twenty-fifth percentile weighs the same or more than 25 percent of the reference population of two-month-old girls, and weighs less than 75 percent of the two-month-old girls in the reference population. They are the most commonly used clinical indicator for assessing the size and growth patterns of individual children in the United States. The problem is, the comparison of baby growth becomes, by extension, a comparison of parenting success and then a competitive sport. Having a baby in a high percentile for growth becomes a mommy bragging right — "My Johnny is in the ninety-fifth percentile" — statistical proof positive that you are doing a good job.

If the anxiety of the weigh-in and the peer pressure for big percentile numbers wasn't enough, I had my own fears. From the very beginning of breastfeeding, I worried if my child was getting enough food. Yes, medical experts tell you if you count five to six wet disposable diapers per day and two to five bowel movements every twenty-four hours with the fastidiousness of a city health inspector, then all is well. But still you wonder. You worry. Not to mention that as superachiever moms raised on test scores, GPAs, performance reviews and living in a "supersize" world, we crave high numbers. We want big. Our society sees plump babies as a sign of good mothering. And, let's face it, we want to boast. As the pediatrician placed my baby on the scale, I couldn't help holding my breath and bracing myself just a little.

So you can imagine the blow to the gut when, after two months of feeling like I had finally nailed the breastfeeding thing, my pediatrician said that my daughter's weight was slightly below average and suggested that I might need to supplement with formula if things weren't ticking upward in two weeks. I was heartbroken. Exclusive breastfeeding for six months was my personal goal, and I didn't want to supplement. She said that my milk supply may be dwindling and that this was very common with women. She told me that I shouldn't feel bad if I needed to add formula and that I had "done well."

What she didn't tell me was that the chart that she was using to gauge my child's growth progress was based on an outdated sample of babies who weren't being fed the way my baby was being fed. That's because until 2006, the standard infant growth charts in the United States were based on a sample of formula-fed infants. In 1977 the National Center for Health Statistics (NCHS), which became part of the CDC in 1987, published a set of growth charts based on the Fels Longitudinal Growth Study. These charts eventually became the standard U.S. growth charts and were later used by the World Health Organization and others to develop global growth curves for infants. The U.S. growth charts became the model for the world. The Fels study, however, was based on a sample of formula-fed Caucasian babies born between 1929 and 1975 in Ohio — infants who weren't even being fed according to the globally recommended infant nutrition standard: breast milk. These babies started solid foods before four months and were being measured every three months, which researchers later realized is too long of an interval for gauging the rapid growth periods during infancy. In addition, relying on a sample of infants from one racial, socioeconomic, and geographic background over a short period of time wasn't ideal for measuring a general infant population. So while pediatricians and health officials were promoting breastfeeding as the best nutrition, they were also comparing all babies to formula-fed babies. We now know that breastfed babies and formula-fed babies grow differently. This important fact was missing from the growth charts being used all over the world prior to 2006.

This isn't a small matter. For over two decades, many governmental and United Nations agencies used the data collected from physicians based on these growth charts to measure the general health and well-being of national populations. That information, in turn, was used to set global infant health policies, determine stages for interventions, and monitor the effectiveness of the recommendations. Growth charts are the core tool of the pediatrician. They are used to determine the degree to which the physiological needs for growth and development are being met during infancy and childhood and to assess a child's nutritional status. Yet generations of mothers and babies were incorrectly subjected to the bottle-based growth charts. Many breastfed infants were misdiagnosed with a failure to thrive and given formula based on these growth charts, causing needless distress to their mothers. I know. I was one of them.

At the same time, inadequate infant growth has been one of the biggest sources of profit for the infant formula industry. One of formula makers' most consistent marketing messages has been that when mother's milk is insufficient, then infant formula is there to ensure optimum growth and wellness. That eventuality could be nearly guaranteed when breastfed babies were measured against charts contradicting their normal growth pattern. It is no wonder that infant formula companies have freely given away growth charts to physicians as promotional material for years. It is a mighty sheet of paper with the power to direct medical advice on infant nutrition and either bolster formula sales or support breastfeeding worldwide. Growth charts are a really big deal.

And for decades they were wrong. It wasn't until the early 1990s that researchers began to document the different growth patterns of breastfed babies and formula-fed babies. Studies show that breastfed babies grow faster during the first few months of life and then tend to "lean out" from month 3 to month 12 when compared with formula-fed babies. Then researchers set out to find if this should be classified as some sort of "faltering" or a normal outcome of breastfeeding even in optimal conditions. One key study by DARLING (Davis Area Research on Lactation, Infant Nutrition and Growth), published in The Journal of Pediatrics in 1991, found that the slower growth of breastfed infants did not cause negative consequences for activity level, time spent sleeping, or achievement of developmental milestones. The report concluded, "infants with slower growth velocity were just as active and were ill no more often in subsequent months than infants who were growing more rapidly." Basically, the slower-growing breastfed babies were just fine.

It wasn't until 2006 (six years after I received my supplementation recommendation) that the World Health Organization released its own growth curve charts, using breastfed babies as the standard for growth, changing our understanding of the differences of how breastfed and formula-fed babies grow. The WHO charts were created from a sample of nearly nine thousand babies who were exclusively or near exclusively breastfed for the first six months. The charts established the breastfed child as the normative model for growth and development around the world. Applying them to formula-fed babies can serve as an early warning to doctors if a formula-fed baby is experiencing excessive weight gain and is therefore at greater risk of being overweight or obesity. "Arguably, the current obesity epidemic in many developed countries would have been detectable earlier if a prescriptive international standard would have been available 20 years ago," the WHO admits, acknowledging the role of two decades of inaccurate growth charts in the course of childhood health. All over the world, babies were misclassified as underweight and given infant formula, which is more calorie-dense. The higher fat content of formula and the propensity to overfeed when using a bottle has been linked to higher rates of childhood obesity. Infant formula also contains unhealthy sugars, some of which have been banned in Europe because of their known link to childhood obesity.

But getting to the critical and yet basic point of having a valid growth chart that works for all babies and is based on the diet that public health experts unanimously agree is best has taken over twenty years. It took less time to put a man on the moon. The Panama Canal was constructed in ten years. How did this happen? Child nutrition researchers, who as a group have been heavily funded by infant formula companies, accepted formula feeding as the norm for their studies. Physicians, who have historically had a financial relationship with infant formula companies, relied on researchers for information about how breastfed babies grew. And institutions responsible for setting guidelines to ensure the health of infants around the world relied, in turn, on those two entities for data and recommendations.

* * *

Thirty-two. That's the number of seconds it took for me to encounter the infant formula marketing at a pediatrician's office on the outskirts of New York City. I walked about ten feet from the office door to the reception desk and, at the check-in window, I picked up a pen and there it was — the words ROSS LABS emblazoned on one side of the pen and a Rosco teddy bear on the other side. The clipboard matched. That day, I was on a reconnaissance mission — visiting various pediatrician and ob-gyn offices in and around New York City to see how long it would take from the moment I entered the office door before I met infant formula marketing — along with the implied message that infant formula is doctor-approved.

My expedition took me to neighborhoods like the Upper East Side, where there were very few traces of infant formula marketing in the waiting or examining rooms, to some forty miles east to the suburbs of Long Island where, infant formula marketing was even more present in ob-gyn offices than in pediatrician offices. All in all, I visited some thirty offices over the span of my "mission," and I only found one physician with absolutely no visible marketing materials in the office or examining room representing the formula brand or the pharmaceutical company that manufactures it. Only one doctor out of thirty who did not give out magazines or giveaway packs full of infant formula coupons and pamphlets to expecting mothers.

Every year Perrigo Nutritionals, makers of Store Brand Formula, conducts a nationwide "Pulse of Pediatricians" survey — conducted by SERMO, the largest online network for physicians. In their most recent findings, 59 percent of pediatricians reported distributing infant formula samples in their offices — despite the fact that the American Academy of Pediatrics adopted a resolution in 2012 advising pediatricians to stop displaying infant formula marketing materials in their offices and clinics.

The participation of physicians' offices in formula marketing programs, from logo-laden growth charts to formula coupons and freebies, has a strong correlation with breastfeeding outcomes. A 2000 study published in Obstetrics and Gynecology showed that mothers who receive formula marketing at the ob-gyn's office have stunted breastfeeding experiences. The randomized, controlled trial of more than five hundred mothers looked at the impact of promotional materials on the first prenatal visit. Mothers received either a formula-company-sponsored information pack on infant feeding or a noncommercial pack. The results showed that among mothers who were uncertain about their plans to breastfeed, those who received the formula marketing packet were 1.7 times more likely to stop breastfeeding before two weeks than those who received the noncommercial information. The study concluded that this was "compelling evidence that obstetric care providers should not participate in formula marketing programs."

Obstetricians and pediatricians exert a powerful influence on women not just because they passively display waiting room materials and give away freebies but because of what they actively say about breastfeeding. In a study of obstetricians and patients at a multispecialty group practice in Massachusetts, just 8 percent of physicians felt their advice on whether and how long to breastfeed was important, but more than one-third of mothers reported that their provider's advice on these topics was very important. This study also found that patient perception of clinicians' opinions is directly correlated with breastfeeding duration. In looking at breastfeeding prevalence at six weeks postpartum, researchers found that 70 percent of women who thought their physician favored breastfeeding were still breastfeeding compared with 54 percent of those who thought their physician had no preference.

Here's what we know thus far: Doctors may not think that mothers are influenced by what they give away or which infant feeding method they support, but mothers are. Their behavior reflects it and that behavior affects infant health and maternal health. In the Store Brand Formula survey, 97 percent of pediatricians said questions about feeding are the most frequently asked category for new parents, with pooping and sleeping coming in second and third place.

If so many parents are asking about feeding, shouldn't pediatricians be the most knowledgeable on all the options, starting with the optimal nutrition as recommended by the American Academy of Pediatrics? And shouldn't the AAP, representing over 64,000 pediatricians and pediatric specialists, be leading the charge for breastfeeding? Instead of being the seemingly strongest and most natural ally, the AAP continues to be heavily supported by infant formula donations, raising questions about its own bias in the infant feeding information it provides to parents. Formula manufacturers have donated $1 million annually to the AAP in the form of a renewable grant that had already netted the AAP $8 million by 1995. The formula industry also contributed at least $3 million toward the building costs of the AAP headquarters. AAP's "Friends of Children Fund" (FCF) is a corporate donor fund used to support "high priority activities" and generate new knowledge about how to care for your children, according to AAP's Web site. In return for a donation, members receive "significant acknowledgment in several AAP publications visible to our 60,000 members," the Web site says. Yet, 89 percent of the top donors — those giving $50,000 or more annually — are infant formula or pharmaceutical companies, including Mead Johnson, Nestlé, Perrigo Nutritionals, Pfizer, and Sanofi Pasteur, one of the largest companies in the world devoted entirely to vaccines. The potential conflicts of interest for parents to receive truly unbiased information from the AAP seem hard to ignore.

Medical schools also play a part. What do doctors learn about breastfeeding in medical school? "Not much," said my current pediatrician. "There was about a day or so on the medical evidence on the benefits of breastfeeding, but nothing about medical problems related to lactation or the science of what's happening in the breast at the anatomical level," he said. Most medical schools don't have any meaningful breastfeeding curriculum that includes in-depth training on the mechanics of breastfeeding, how to identify and treat lactation problems, and how breastfed babies grow and develop. Many of those teaching at medical schools are of the generation that were trained at a time when science aimed to bring better living and the chemistry behind infant formula was thought to trump breast milk. The message at many medical schools is that understanding breastfeeding is not in a physician's job description. In fact, lactation holds the dubious distinction of being the only bodily function for which modern medicine has virtually no training or knowledge. Doctors know how to treat and prescribe for erectile dysfunction, but lactation dysfunction doesn't even exist as a diagnosis. Nevertheless, where medical schools have failed to educate, infant formula companies have been more than happy to fill the gap. In the absence of independent medical training, doctors and mothers alike have relied on the commercial industry — the one supplying and profiting from the substitute product — to provide so-called unbiased education and guidance. Every year, the Abbott Nutrition Every year, the Abbott Nutrition Institute hosts conferences to "educate" thousands of physicians and nurses on infant nutrition. This is like going to a Toyota car dealer to learn about the benefits of a Buick. Or imagine thousands of licensed dieticians being trained at a McDonald's Nutrition Institute.

Editorial Reviews

12/05/2016Journalist Allers (coauthor of The Mocha Manual to Military Life) thinks the slogan “Breast Is Best” should really be “Breast Is Complicated” as she comes out swinging against simplistic probreastfeeding arguments. Though some background is necessary, too much of Allers’s focus is on examples over a decade old, including a controversial advertising campaign from 2002, a controlled trial from 2001, and infant growth charts that were based on formula-fed babies until 2006. The resulting impression is that she doesn’t have much new to say about 21st-century trends. Allers does have one unusual target—feminism—and though much of her ire targets older second-wave ideas, such as the masculinization of women in pursuit of workplace equality, she also blames the well-meaning approach of lactation activists for making breastfeeding seem aggressive or radical rather than normal. She also criticizes third-wave ideas, such as placing breastfeeding in the context of “choice feminism” rather than public health and social justice, and calls out the middle-class focus on workplace accommodations in corporate environments. Only at the end does Allers step back from the anger to propose approaches for moving forward, and then her ideas are too vague to be useful or actionable. Agent: Stacey Glick, Dystel & Goderich. (Jan.)

Publishers Weekly

"With abundant research to back her narrative, journalist Allers, who has two children, shows how and why American women have been made to feel ashamed of breast-feeding...Allers makes the message loud and clear: since breast-feeding provides the most benefits for mother and child, for those who are capable of doing so, it should be the feeding method of choice. Easily digested research and personal stories in support of breast-feeding and its importance to mothers and their children." -Kirkus Reviews

"Formula companies make millions by convincing women they aren’t capable of one of their most basic bodily functions, and have spent millions of marketing dollars aimed at women, doctors, hospitals, scientists and policymakers to hammer this point home for the past century. Allers is...transform[ing] the narrative surrounding breast-feeding into an empowering message." - The Washington Post

From the Publisher

01/01/2017Breastfeeding is one of many polarizing issues facing women today. Allers, a recognized breastfeeding advocate, director of the First Food Friendly Community Initiative, and author of the "Mocha Manual" series, presents an in-depth examination of the structural, economic, and cultural barriers to breastfeeding. In the first chapters, Allers reviews the scientific support for breastfeeding and how the corporate world, motivated by profit, has undermined "good science" and created confusion and doubt. She then tackles structural and cultural barriers such as workplace biases, the lack of sufficient maternity leave and physician training, and even the quality of breast pumps. Allers supports her conclusions by citing scientific research, statistics, and specific examples provided by mothers and others involved in the breastfeeding community. This book concludes with a look ahead and specific recommendations that reimagine a world that truly supports breastfeeding. The portion of the narrative that will undoubtedly lead to discussion is Allers's assertion that feminists, through the choice movement, have actually undermined breastfeeding. Index not seen. VERDICT By detailing the many societal roadblocks to providing honest and effective support for mothers, this is an important addition to the breastfeeding literature that will invite discussion and a reexamination of social and cultural practices.—Theresa Muraski, Univ. of Wisconsin-Stevens Point Lib.

Library Journal

2016-11-07Why breast-feeding is often frowned upon in the United States despite the well-documented health benefits for both mother and child.Even though breast-feeding is recommended by the World Health Organization, the Centers for Disease Control and Prevention, the United Nations, and many other international organizations, the topic of breast-feeding is controversial, especially in the U.S. With abundant research to back her narrative, journalist Allers (The Mocha Manual to Turning Your Passion into Profit: How to Find and Grow Your Side Hustle in Any Economy, 2009, etc.), who has two children, shows how and why American women have been made to feel ashamed of breast-feeding. "The breastfeeding narrative, both historical and present-day, is a cautionary tale about maternal bodies, good or bad mothers, and how our bodies are measured and assessed," she writes. "Breastfeeding shows us all the ways, as women, that we have been imagined, constructed, created, and controlled by economics, science, the media, and other so-called authoritative sources." Allers chronicles the evolution of infant care from breast-feeding and the use of wet nurses to the introduction of mass-produced infant formulas to the return of breast-feeding activism, with all its inherent problems as women continue to work while still providing the nourishment their children need. The author also examines the role big corporations play in controlling this highly personal act, the problems breast-feeding creates when breasts are so widely representative of a woman's sexuality, and how feminists have actually hindered the recently revived breast-feeding movement. Allers makes the message loud and clear: since breast-feeding provides the most benefits for mother and child, for those who are capable of doing so, it should be the feeding method of choice. Easily digested research and personal stories in support of breast-feeding and its importance to mothers and their children.

Customer Reviews

Most Helpful Customer Reviews

The Big Letdown: How Medicine, Big Business, and Feminism Undermine Breastfeeding 5 out of 5based on
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3 reviews.

Anonymous

More than 1 year ago

Amazingly written, well researched, and profoundly sad to hear the history and challenges women have faced, and are still facing in our country and elsewhere. KSA has summarized a battle and story that many may not want to hear, but that women NEED to hear. Only when we understand the history, and the current state of infant feeding, can we begin to empower ourselves as women to demand change. With all the bad information out there, including from the doctors we trust for our children's health and care, its refreshing to see such a well presented body of facts. If mothers and families don't start demanding better for our children and ourselves, who will?
Who is keeping the formula companies and pediatricians accountable if not us?

Anonymous

More than 1 year ago

This book is the definitive work on how we undermine woman's infant feeding decisions and let them down with breastfeeding support. I highly recommend this book to parents, caregivers, health care providers and public health advocates who work directly to support breastfeeding.
This book will leave you with deep insights into what's really going on out there and the forces that derail women from reaching their breastfeeding goals. In addition I hope it inspires you to reach into your community to reflect on the barriers that are happening there and use the insights from this book to help you become active in dismantling them.

Michael_B22

More than 1 year ago

This book was great. I'll be honest, as a guy I didn't know what to expect. It's not necessarily something that I would have picked up on my own, but a friend recommended it and I couldn't put it down. Ms. Allers does a phenomenal job of bringing in all of the factors working against women who are just trying to feed their babies, she does it through creative story telling, but uses facts and figures to prove her point. Very well done!